Medical Record Documentation of Patients’ Hearing Loss by Physicians

Abstract

BACKGROUND

Anecdotal evidence suggests that hearing loss, even when sufficient to prevent full access to spoken communication, often is underreported by patients and not documented by physicians. No published studies have investigated this issue quantitatively.

OBJECTIVE

To assess the documentation of hearing loss in comprehensive physician notes in cases where the patients are known to have substantial binaural loss.

DESIGN

Electronic medical record (EMR) notes for 100 consecutive patients with substantial binaural hearing loss were reviewed retrospectively at a large academic medical center. All records reviewed were created within 2 years before the patient’s audiometry. Comprehensive physician notes containing the headings “History” and “Physical Exam” were examined for documentation of hearing loss and scored as: no mention of loss; finding of loss; or hearing reported as normal.

PARTICIPANTS

Consecutive adult patients with substantial binaural hearing loss by audiometry who also had a comprehensive medical assessment in their electronic medical record created within 2 years before audiometry.

RESULTS

Thirty-six percent of EMRs had no mention of hearing loss, 28% reported some loss, and 36% percent indicated that hearing was normal.

CONCLUSIONS

Substantial hearing loss, sufficient to prevent effective communication in the medical setting, often is underdocumented in medical records.